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Clin Med Final Material- Semester 2 > Uterine Disorders- Dobbs > Flashcards

Uterine Disorders- Dobbs Flashcards

1
Q

Leiomyoma (Uterine Fibroid):

  • how common?
  • Describe
A

-Common, benign uterine tumor

=Discrete, round, firm, often multiple uterine tumor composed of smooth muscle and connective tissue

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2
Q

Leiomyoma aka fibroids depend on ______

A

estrogen

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3
Q

Fibroids classified by location: (list types)

A

subserous, intramural, submucous, intraligamentous, pedunculated, parasitic (blood supply from an organ to which it becomes attached), and cervical

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4
Q

Uterine Fibroid:

-clinical features:

A

Asymptomatic
Firm, enlarged, irregular uterine mass
Pressure or fullness in pelvis
Menorrhagia, metrorrhagia, intermenstrual bleeding, and dysmenorrhea common

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5
Q

Uterine Fibroid:

-What is the MC presenting symptom?

A

bleeding

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6
Q

Other Sx associated with uterine fibroid

A
  • Anemia

- Infertility may be due to a myoma that significantly distorts the uterine cavity

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7
Q

Uterine Fibroid:

Diagnosis: (hint: several choices)

A 
Pelvic ultrasound
D&C
Saline Hysteroscopy
Hysterosalpingography
Laparoscopy
Pelvic MRI/CT
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8
Q

Uterine Fibroid:

-Tx?

A
  • Observation
  • Symptomatic patients may have myomectomy or D&C
  • Depo-provera (medroxyprogesterone acetate)150mg IM every 28 days or Danazol (synthetic modified testosterone) 400-800 mg daily can be used to help stop bleeding – usually treat anemia prior to surgery
  • Uterine arterial embolization or endometrial ablation (no desire for future fertility)
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9
Q

Uterine Fibroid:

-what is the final step?

A

hysterectomy

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10
Q

Endometriosis= a condition where the endometrial tissue is found ______

A

outside of endometrial cavity

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11
Q

Common location for ectopic endometrial tissue:

A
  • Ovaries
  • Uterosacral ligament
  • GI tract
  • May also be as distant as lungs and brain
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12
Q

Endometriosis Epidemiology :

-exact prevalence is _____

A

-unknown because surgery is required for dx

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13
Q

Endometriosis:

-usually occurs in women of _________

A

**reproductive age–20’s-30’s

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14
Q

Endometriosis:

-is found in ___% of infertile women

A

25%

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15
Q

Endometriosis:

Smallest (earliest) implants are ______

A

red, petechial lesions on peritoneal surface

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16
Q

Endometriosis:

-describe older lesions

A

Dark brown, blue or black implants are older filled with menstrual debris (powder burn lesions) – can reach 5-10 mm
-Surrounding tissue is thickened and scarred

-Adhesions develop

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17
Q

Endometriosis:

Describe Cysts on ovaries

A

called endometriomas or “chocolate cysts”

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18
Q

Endometriosis:

-Cysts grow to ____cm in size

A

several cm

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19
Q

Endometriosis:

Erodes into underlying tissue and distorts remaining organs with ______

A

implants

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20
Q

List the 3 theories of endometriosis:

A
  • Retrograde menstruation- reflux of endometrial cells
  • Vascular and lymphatic dissemination
  • Transformation of peritoneal cells
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21
Q

Other theories of endometriosis:

A

-Genetic influences have been considered

-

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22
Q

Endometriosis:

-___% of endometriosis Pts’ first-degree female relatives are diagnosed with the disease

A

7-9%

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23
Q

Endometriosis:

-possible role for _____ allele

A

HLA-B7

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24
Q

Endometriosis:

-suspicion based on history, Sx, and ______

A

physical exam, lab or imaging information – infertility, dysmenorrhea, and dyspareunia

-Endometrial implants and cysts respond to the hormonal fluctuations of the menstrual cycle

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25
Q

Endometriosis:

-List the 3 D’s

A

**Dysmenorrhea, Dyspareunia, Dyschezia

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26
Q

Dyspareunia=

A

painful intercourse

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27
Q

Dyschezia=

A

constipation associated with a defective reflex for defecation

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28
Q

Dysmenorrhea=

A

painful menstruation

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29
Q

Endometriosis diagnosis is based on:

A

tissue biopsy with laproscopy

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30
Q

Endometriosis;

women may be asymptomatic or may have severe ______

A

pelvic pain

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31
Q

T/F: Infertility is common with endometriosis

A

true

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32
Q

Endometriosis:

-increased risk:

A
  • Family hx
  • Early menarche
  • Long duration of menstrual flow
  • Heavy bleeding during menses
  • Shorter cycles
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33
Q

Decreased risk for endometriosis:

A

> 4 hr/wk exercise, higher parity, longer duration of lactation

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34
Q

Endometrial DDx:

A 
PID 
Pelvic adhesions
Gastrointestinal dysfunction
Dysmenorrhea
Ovarian cysts
Ectopic pregnancy
Adnexal torsion
-Rupture of corpus luteum cyst or ovarian neoplasm
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35
Q

Endometriosis Clinical Features :
-may present w/ dysmenorrhea, _______, _______ (difficulty passing bowel movements), intermittent spotting, pelvic pain, and infertility

A

dysmenorrhea, dyspareunia, dyschezia

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36
Q

Endometriosis Clinical Features :

stimulated by hormones, and implants grow ______

A

large and may undergo secretory change and bleed

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37
Q

Endometriosis:
Pain comes from pressure and _______ within and around the lesions, traction on adhesions, and number of implants and proximity to nerves

A

inflammation

-Severe pain associated with deeply infiltrating lesions

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38
Q

Endometriosis:

-On Physical exam:

A
  • Tender nodules in posterior vaginal fornix
  • Pain with uterine motion
  • Tender adnexal masses
  • None
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39
Q

endometriosis:

-diagnosis of endometriosis is substantiated by direct visualization of _______

A

implants during laparoscopy or laparotomy and tissue biopsy

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40
Q

endometriosis: diagnosis

- histological _______

A

findings

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41
Q

Endometriosis: tx

A
  • Depends on severity of symptoms, location of disease, and desire for childbearing
  • Expectant (watch and wait)
  • NSAIDs for discomfort
  • Surgery may be conservative or definitive (may remove large endometriomas)
  • Medica tx
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42
Q

Endometriosis:

describe medical treatment

A
  • Oral contraceptives (progesterone)
  • IUD
  • Progesterone therapy (Depo Provera or Mirena)
  • Danazol (19–nortestosterone derivative)
  • GnRH agonists (Lupron)
43
Q

Pregnancy and Endometriosis:

-can pregnancy improve or worsen endometriosis?

A
  • Pregnancy may temporarily improve or worsen endometriosis symptoms
  • Pregnancy does not cure endometriosis
44
Q

Adenomyosis Clinical Features:

A 
Asymptomatic
Severe dysmenorrhea
Abdominal pressure and bloating 
Symmetrically enlarged uterus
Heavy bleeding
45
Q

Adenomyosis:

- the classic patient is middle aged, severe ______, hx of ______

A

dysmenorrhea, history of childbearing, symmetrically enlarged uterus, and menorrhagia

46
Q

Adenomyosis Diagnosis:

A
  • Pelvic US
  • MRI
  • Hysterectomy is definitive diagnosis
47
Q

Adenomyosis tx:

A

NSAIDs
Hormones
Hysterectomy

48
Q

cystocele=

A

= bladder prolapse (aka wall between the bladder and vagina weakens)

49
Q

Common for bladder and _____ to prolapse together, called ______

A
  • **bladder & urethra

- called Cystourethrocele (=MC type of prolapse)!!

50
Q

Rectocele=

A

prolapse of rectum or large bowel

51
Q

Uterine Prolapse= the uterus can be sen ______

A
  • *descending into the vagina

- cervix is clearly visible at vaginal introitus

52
Q

Uterine Prolapse:

-typically occurs after_____

A

pregnancy, labor, and vaginal delivery but also may occur in patients without children

53
Q

Uterine Prolapse:

-Risk increases to ___% after menopause for all women

A

50%

-More common in white women

54
Q

Uterine Prolapse:

-also common with any condition that increases intra-abdominal pressure–including:

A

obesity, chronic cough (asthma or COPD), heavy lifting, pelvic tumors, ascites, or constipation increase risk

55
Q

Uterine Prolapse: Clinical Features (list)

A
  • Sx are usually worse after prolonged standing (gravity)!
  • May be relieved by lying down
  • Vaginal fullness
  • Lower abdominal pain
  • Low back pain
  • **“Falling out sensation”
  • May also have cystocele, rectocele, or enterocele
56
Q

Uterine Prolapse Grading:

Grade 0=

A

No prolapse (normal)

57
Q

Uterine Prolapse Grading:

Grade 1=

A

Descent is >1cm above hymen

58
Q

Uterine Prolapse Grading:

Grade 2=

A

Descent to hymen

59
Q

Uterine Prolapse Grading:

Grade 3=

A

– Protrudes, but no less than 2cm total vaginal length

60
Q

Uterine Prolapse Grading:

-grade 4=

A

Total eversion of lower genital tract

61
Q

Uterine Prolapse Management:

  • referral?
  • non-surgical approaches include:
A
  • Refer to GYN!
  • Non-surgical: weight reduction, smoking cessation, pelvic muscle exercises, and use of a vaginal pessary
  • Surgical approach
62
Q

Abnormal uterine bleeding includes:

A

abnormal menstrual bleeding and bleeding due to other causes such as pregnancy, systemic disease, or cancer.

63
Q

Exclusion of all possible pathologic causes of AUB establishes the diagnosis of _______

A

dysfunctional uterine bleeding.

**In general, DUB is correlated with endocrine dysfunction

64
Q

AUB:

Bleeding in any of the following situations is abnormal: (list)

A 
Bleeding between periods
Bleeding after intercourse
Spotting anytime in menstrual cycle
Bleeding heavier or for more days than normal
Bleeding after menopause
65
Q

AUB can occur at any ___

A

age

66
Q

AUB: why is it difficult to dx/manage?

A
  • Diagnosis and management of AUB present some of the most difficult problems in gynecology
  • Patient may not be able to localize source of bleeding
  • NOTE: **more than one cause may be present such as fibroids and cancer
67
Q

AUB:

In child-bearing women, a complication of ______ must be considered

A

** pregnancy

68
Q

Menorrhagia=

Hypomenorrhea=

A

Regular interval between periods, excessive flow and duration

Decreased flow during normal duration of regular period

69
Q

Metrorrhagia=

A

Irregular intervals of menses, excessive flow and duration

70
Q

Polymenorrhea=

A

Shortened interval between periods , < 19-21 day interval

71
Q

Menometrorrhagia=

A

Irregular or excessive bleeding during periods and between periods

72
Q

Oligomenorrhea=

A

Lengthened interval between periods, > 35 days intervals

73
Q

AUB Causes:

A 
Pregnancy
Miscarriage
Ectopic pregnancy
Adenomyosis
Birth control (IUDs or OCPs)
Hormones
STIs
Fibroids 
Clotting disorders
Polyps
Endometrial hyperplasia
Cancer
74
Q

Causes of AUB:

-Structural causes: PALM

A

**Polyp
Adenomyosis
Leiomyoma
Malignancy & hyperplasia

75
Q

Causes of AUB:

-nonstructural causes: COEIN

A 
Coagulopathy
Ovarian dysfunction
Endometrial process
Iatrogenic
Not yet classified
76
Q

Evaluation of AUB

A
  • Note amount of menstrual flow
  • Menstrual period length and amount
  • Note LMP, LNMP
  • Age at menarche & menopause
  • Medication taken, Supplements/herbs
  • Systemic disease (renal, adrenal, hepatic, or thyroid)
  • Episodes of intermenstrual bleeding
  • Changes in general health
  • Pt to keep record of bleeding patterns - differentiate abnormal & variation of normal
  • Abdominal pain
  • Dyspareunia
  • Galactorrhea
  • Hirsutism, acne
  • Weight gain
  • Petechiae, ecchymosis
  • Pallor
77
Q

Eval of AUB:

-PE?

A
  • **Pelvic exam and abdominal exam
  • Look for masses
  • Symmetrically enlarged uterus most typical with Adenomyosis
  • Enlarged, irregular uterus consider leiomyoma
  • Atrophic & inflammatory vulvar and vaginal lesions can be visualized
  • Cervical polyps and invasive lesions
  • Rectovaginal exam is especially important- palpate uterus
78
Q

AUB Work-Up:

  • Lab tests?
  • Additional tests?
A
  • History and Physical
  • Lab tests – CBC, bHCG, TSH, HbA1C, STI testing

-Additional tests – Pap smear,
pelvic US, endometrial biopsy, hysteroscopy, D&C, consider CT or MRI of abdomen and pelvis

-**Refer to OB-GYN

79
Q

Recommendations for AUB:

  • First consider the situation/age
  • -Adolescent
  • -19-39 yo
  • -and >___yo
A

40

80
Q

EVALUATION OF AUB:

Cytological exam

A
  • Pap smears can help screen for cervical dysplasia – BUT Not reliable for diagnosis of endometrial abnormalities
  • Endometrial cells in a postmenopausal women abnormal on PAP
81
Q

Other evaluation tools:

A
  • Endometrial tissue biopsy
  • Transvaginal ultrasound
  • Hysteroscopy
82
Q

Describe Hysteroscopy and why is it important in eval of pathology in the uterine cavity?

A
  • Direct visualization of the endometrium via camera into endometrial cavity with immediate biopsy. Done as outpatient.
  • ** Gold standard for evaluation of pathology in the uterine cavity**
83
Q

PELVIC ULTRASOUND

A
  • Has become an integral part of the gynecological pelvic exam
  • Scan done transabdominally or transvaginally
  • **Transvaginal U/S with empty bladder gives greater details of pelvic organs
  • Transabdominal U/S performed with full bladder, enables a wider but less discriminative exam of pelvis
84
Q

AUB – Endometrial Biopsy

A
  • Use of a curette, cervical dilation not always needed
  • Small samples of tissue removed from the endometrium
  • Samples are looked at under a microscope to identify abnormal cells
  • Tissue obtained sometimes may be inadequate for dx so hysteroscopy or D&C must be performed
85
Q

D & C - Dilatation and Curettage (describe)

A

=a procedure to remove tissue from inside the uterus.
-Procedure used to dx and treat certain uterine conditions such as heavy bleeding or to clear the uterine lining after a miscarriage or abortion.

-Done under local anesthesia, almost always in an outpatient or ambulatory surgical setting.

86
Q

Treatment of AUB:

-primary goal=

A
  • Determine underlying cause
  • Resume regular shedding of the endometrium
  • Regulation of uterine bleeding
  • **Rule out cancer
87
Q

Treatment of AUB:

-Progesterone->

A

Progesterone agent – Depo injections or IUD may be helpful in some cases

88
Q

Treatment of AUB:

OCPs–>

A
  • Suppresses the endometrium

- Established regular predictable withdrawal cycle

89
Q

Treatment of AUB:

-surgical?

A

Endometrial ablation, surgical management, or hysterectomy

90
Q

Postmenopausal bleeding is defined as bleeding that occurs after _____

A

**12 months of amenorrhea in a middle-aged woman

91
Q

What lab value (level) is very helpful for postmenopausal bleeding?? (KNOW)

A
  • FSH levels are particularly helpful in the differential diagnosis of menopause verses hypothalamic amenorrhea.
  • **A FSH > 30mIU/mL is highly suggestive of menopause and estradiol below 20.
92
Q

Postmenopausal bleeding is more likely to be caused by ______ _______ than is bleeding in younger women, and MUST ALWAYS BE INVESTIGATED

A

**pathologic disease

93
Q

Neither normal (functional) bleeding or _____ _____ should occur after menopause

A

abnormal bleeding

94
Q

Postmenopausal bleeding:

-MC cause=

A

**the use of exogenous hormones.

KNOW!!

95
Q

Postmenopausal bleeding:

-what is vital for Pts?

A

Careful history taking becomes vital since patients may not follow specific instructions on the use of estrogens and progesterone therapy

96
Q

Endometrial Cancer:
-how common?
Demographic?
-Peak incidence=

A
  • **MC GYN cancer
  • Postmenopausal women make-up ~75% of cases (MC in white females)

-Peak incidence of onset is in 7th decade

97
Q

Endometrial CA:

  • what provides a protective effect?
  • what increases risk?
A

OCPs (combined estrogen and progesterone) have protective effect

-exposure to unopposed estrogen increases risk

98
Q

Endometrial CA:

-MC type=

A

Adenocarcinoma is the MC type, ~80% of cases of endometrial carcinoma in US

99
Q

Endometrial Cancer Risk Factors:

A 
Increasing age
Obesity
Nulliparity/Infertility
Late menopause
Early menarche
Diabetes
Unopposed estrogen
Genetic predisposition 
Prior pelvic radiation
100
Q

Endometrial Cancer Clinical Features:

-cardinal Sx=

A
  • *Cardinal symptom is abnormal uterine bleeding
  • Abnormal vaginal discharge
  • Intermittent spotting
  • Lower abdominal cramps and pain
101
Q

Endometrial Cancer:

-List the 4 routes of endometrial CA spread

A
  • Direct Extension
  • Lymphatic mets
  • Peritoneal implants after transtubal spread
  • Hematogenous spread
102
Q

Endometrial Cancer Diagnosis:

A
  • Incidental on Pap Smear
  • Pelvic ultrasound
  • Dilation and curettage
  • Endometrial biopsy
  • **REFER TO GYN!
103
Q

Endometrial Cancer Management:

A
  • **Refer to GYN!
  • Total hysterectomy combined with salpingo-oophorectomy (basis of treatment and staging)
  • Radiation
  • Chemotherapy

Clin Med Final Material- Semester 2 (22 decks)

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